Healthcare Provider Details

I. General information

NPI: 1881209948
Provider Name (Legal Business Name): CAROLYN MARIE PECK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

4714 CREST AVE SE
ALBUQUERQUE NM
87108-4507
US

V. Phone/Fax

Practice location:
  • Phone: 505-803-0013
  • Fax:
Mailing address:
  • Phone: 505-803-0013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: